Establishment of a multisite umbrella cohort study protocol to describe the epidemiology and aetiologies of acute undifferentiated febrile illness in Latin America.

INTRODUCTION: Acute undifferentiated febrile illnesses (AUFIs) impose a large burden in the tropics. Understanding of AUFI's epidemiology is limited. Insufficient diagnostic capacity hinders the detection of outbreaks. The lack of interconnection in healthcare systems hinders timely response. We describe a protocol to study the epidemiology and aetiologies of AUFI and pathogen discovery in strategic areas of Latin America (LA). METHODS AND ANALYSIS: Global Infectious Diseases Network investigators comprising institutions in Colombia, Dominican Republic, México, Perú and the USA, developed a common cohort study protocol. The primary objective is to determine the aetiologies of AUFI at healthcare facilities in high-risk areas. Data collection and laboratory testing for viral, bacterial and parasitic agents are performed in rural and urban healthcare facilities and partner laboratories. Centralised laboratory and data management cores deploy diagnostic tests and data management tools. Subjects >6 years with fever for <8 days without localised infection are included in the cohort. They are evaluated during the acute and convalescent phases of illness. Study personnel collect clinical and epidemiological information. Blood, urine, nasal or pharyngeal swabs and saliva are collected in the acute phase and blood in convalescent phase. Specimens are banked at -80°C. Malaria, dengue and COVID-19 are tested onsite in the acute phase. The acute-phase serum is PCR tested for dengue, chikungunya, Venezuelan equine encephalitis, Mayaro, Oropouche, Zika, and yellow fever viruses. Paired convalescent and acute serum antibody titters are tested for arbovirus, Leptospira spp, and Rickettsia spp. Serum is used for viral cultures and next-generation sequencing for pathogen discovery. Analysis includes variable distributions, risk factors and regression models. Laboratory results are shared with health authorities and network members. ETHICS AND DISSEMINATION: The protocol was approved by local ethics committees and health authorities. The results will be published in peer-reviewed journals. All study results are shared with local and regional health authorities.

Density of Aedes aegypti and dengue virus transmission risk in two municipalities of Northwestern Antioquia, Colombia.

The high infestation of Aedes aegypti populations in Urabá, Antioquia, Colombia represents a risk factor for increased dengue morbidity and mortality. This study aimed to determine the risk of dengue transmission by estimating the population of Ae. aegypti using entomological indices, density of females per dwelling and inhabitant, and virological surveillance in two municipalities in Colombia. A cross-sectional study was conducted with quarterly entomological surveys in three neighborhoods of Apartadó and Turbo between 2021 and 2022. Aedes indices and vector density per dwelling and per inhabitant were calculated. The Kernel method was used for spatial analysis, and correlations between climatic variables and mosquito density were examined. Virus detection and serotyping in mosquitoes was performed using single-step reverse transcription polymerase chain reaction. The housing, reservoir, and Breteau indices were 48.9%, 29.5%, and 70.2%, respectively. The mean density of Ae. aegypti was 1.47 females / dwelling and 0.51 females / inhabitant. The overall visual analysis showed several critical points in the neighborhoods studied. There was significant correlation of vector density and relative humidity and precipitation in the neighborhoods 29 de noviembre and 24 de diciembre. Additionally, serotypes DENV-1 and DENV-2 were found. The overall indices for dwellings, reservoirs, and Breteau were lower than those recorded in 2014 in Urabá. The vector density results in this study were similar to those reported in other studies conducted in Latin America, and vector infection was detected. The Aedes and density indices are complementary, emphasizing the importance of continuous surveillance of Ae. aegypti to inform appropriate control strategies and prevent future dengue outbreaks in these municipalities.

Etiological characterization of acute undifferentiated febrile illness in Apartadó and Villeta municipalities, Colombia, during COVID-19 pandemic.

Background: Acute undifferentiated febrile illness (AUFI) is one of the leading causes of illness in tropical regions. Although malaria is the most important cause, other pathogens such as Dengue (DENV), Leptospira and recently, Coronavirus Disease 2019 (COVID-19) have gained importance. In Colombia, few studies aimed to identify the etiology of AUFI. Most of them performed in Apartadó and Villeta municipalities, identifying the active circulation of several pathogens. Thus, we conducted a cross-sectional study in these municipalities to characterize the etiologies of AUFI during COVID-19 pandemic. Methods: An active surveillance was conducted between September and December 2021 in local hospitals of Apartadó and Villeta municipalities. Febrile patients were enrolled after voluntarily agreeing to participate in the study. Ten different etiologies were evaluated through direct, serological, molecular and rapid diagnostic methods. Results: In Apartadó a confirmed etiology was found in 60% of subjects, DENV (25%) being the most frequent, followed by leptospirosis (16.7%), malaria (10%), COVID-19 (8.3%), spotted fever group (SFG) rickettsiosis (6.7%) and Chikungunya (1.7%). In Villeta, a specific etiology was confirmed in 55.4% of patients, of which SFG rickettsiosis (39.3%) was the most frequent, followed by leptospirosis (21.4%), DENV (3.6%) and malaria (1.8%). No cases due to Mayaro, Yellow Fever, Oropouche and Venezuelan Equine Encephalitis viruses were detected. Conclusion: We confirm the relevance of dengue fever, leptospirosis, SFG rickettsiosis, COVID-19 and malaria as causes of AUFI in the municipality of Apartadó, and highlight the great importance of SFG rickettsiosis as the main cause of AUFI in the municipality of Villeta.

Molecular Diagnosis as an Alternative for Public Health Surveillance of Leptospirosis in Colombia.

Leptospirosis represents a public health problem in Colombia. However, the underreporting of the disease is an unfortunate reality, with a clear trend towards a decrease in cases since 2019, when the guidelines for its confirmatory diagnosis changed with the requirement of two paired samples. The purpose of this review is to highlight the importance of leptospirosis. While the access to rapid diagnosis is available at practically all levels of care for dengue and malaria, leptospirosis-a doubly neglected disease-deserves recognition as a serious public health problem in Colombia. In this manner, it is proposed that molecular tests are a viable diagnostic alternative that can improve the targeted treatment of the patient and the timeliness of data and case reporting to SIVIGILA, and reduce the underreporting of the disease. Taking advantage of the strengthened technological infrastructure derived from the SARS-CoV-2 pandemic for molecular diagnosis in Colombia, with a network of 227 laboratories distributed throughout the national territory, with an installed capacity for PCR testing, it is proposed that molecular diagnosis can be used as an alternative for early diagnosis. This would allow case confirmation through the public health network in Colombia, and, together with the microagglutination (MAT) technique, the epidemiological surveillance of this disease in this country would be strengthened.

Prevalence and risk factors of anemia in the mother-child population from a region of the Colombian Caribbean.

BACKGROUND: Despite Colombia's robust well-child visits program, Colombian children and mothers still suffer from anemia, especially in populations of lower socioeconomic status. In this study, we aimed to quantify the prevalence and risk factors among mothers and their children attending their well-child visits in Apartadó, a municipality in the Urabá region of the Colombian Caribbean. METHODS: There were 100 mother-child pairs enrolled in this secondary data-analysis study from a health facility in the municipality of Apartadó, Urabá, Colombia, during well-child visits. Self-reported data included child illnesses in the past two weeks (diarrheal, fever, or respiratory symptoms), child feeding practices (breastfeeding, complementary feeding), child vaccinations, and demographic characteristics (mother's and child's age, mother's education, marital status, race, and child sex) and socioeconomic status. Mother and child anthropometry data were collected via standardized weight and height measurements. Mother or child anemia status was collected via a blood test. Chi-squared tests and multivariable logistic regression were used to assess associations between risk factors and anemia. RESULT: The anemia prevalence in children (74%) and mothers (47%) was higher than the Colombian national prevalence. Reported child comorbidities in the preceding two weeks were not significantly associated with child anemia and included respiratory illnesses (60%), fever (46%), and diarrhea (30%). Stunting (8%) was not significantly associated with anemia. Wasting (0%) was not observed in this study. Reported child breastfeeding and complementary feeding were also not significantly associated with child anemia. In adjusted models, the child's significant risk factors for anemia included the mother's "Mestiza" race (OR: 4.681; 95% CI: 1.258, 17.421) versus the Afro-Colombian race. Older children (25-60 months) were less likely to develop anemia than younger (6-24 months) children (OR: 0.073; 95% CI: 0.015, 0.360). CONCLUSIONS: The finding of high anemia prevalence in this study advances our understanding of child and maternal anemia in populations of low socioeconomic status where health care is regularly accessed through well-child programs.

Case Report: Necrotizing Erythema Nodosum as a Manifestation of Lepromatous Leprosy Relapse 50 Years after the Initial Infection.

Leprosy is a chronic infection caused by Mycobacterium leprae and Mycobacterium lepromatosis that preferentially compromises peripheral nerve, skin, and mucous membranes. Colombia achieved the goal of leprosy elimination in 1997. However, in Urabá (Colombia), there has been an increase in leprosy cases beginning in 2020. This case report shows a leprosy relapse 5 decades after the initial infection debuted as a necrotizing erythema nodosum leprosum. Therefore, long-term follow-up of patients with risk factors for relapse is emphasized, especially those treated before the standard of multidrug therapy (dapsone, clofazimine, and rifampin). This case report stresses the importance the importance of clinical follow-up and surveillance of patients with these events of interest for the public health.

Role of cytokines, chemokines, C3a, and mannose-binding lectin in the evolution of the chikungunya infection.

The pathogenesis of the severity of chikungunya infection is not yet fully understood. OBJECTIVE: To assess the role of the cytokines/chemokines and system of complement in the evolution of chikungunya infection. METHODS: In both acute and chronic phases, we measured the serum levels of 12 cytokines/chemokines and two complement mediators: mannose-binding lectin (MBL) and C3a, in 83 patients with chikungunya infection and ten healthy controls. RESULTS: During the acute phase, 75.9% of the patients developed musculoskeletal disorders, and in 37.7% of them, these disorders persisted until the chronic phase. In general, patients had higher levels of cytokines than healthy controls, with significant differences for IFN-γ, IL-6, IL-8, IL-10, and MIP-1. Most cytokines exhibited a downward trend during the chronic phase. However, only IL-10, and MIP-1 levels were significantly lower in the chronic phase. Additionally, these levels never decreased to concentrations found in healthy controls. Moreover, MBL levels were significantly higher in the acute phase compared with the chronic phase. C3a levels were significantly higher in patients with musculoskeletal disorder compared with patients without it, in both acute-phase 118.2 (66.5-252.9), and chronic phase 68.5 (64.4-71.3), P < 0.001. Interestingly, C3a levels were significantly higher when patients had a severe disease version. Besides, in the acute phase, C3a levels were higher in patients that suffer arthritis as opposed to when they suffer arthralgia, 194.3 (69.5-282.2), and 70.9 (62.4-198.8), P = 0.013, respectively. CONCLUSIONS: Our results showed an immunological response that persisted until the chronic phase and the role of the complement system in the severity of the disease.

Leptospirosis and rickettsiosis, a diagnostic challenge for febrile syndrome in endemic areas / [Leptospirosis y rickettsiosis, reto diagnóstico para el síndrome febril en zonas endémicas].

This is the case of a 50-year-old male from the region of Urabá, Colombia, with a mixed infection by Rickettsia rickettsii and Leptospira interrogans serovar Copenhageni ST78 and negative test for malaria and dengue fever. The patient presented with febrile syndrome and was unresponsive to systemic antibiotic treatment, who finally died in the intensive care unit. We established the postmortem diagnosis through molecular typification of the two etiological agents. In the inspection at the patient's home, we found a Rattus rattus specimen infected with L. interrogans of the same serovar found in him. We found no ticks parasitizing the domestic animals cohabitating with the patient. This case of a mixed infection with progressive and fatal symptoms in a patient with occupational risk in a tropical disease endemic zone highlights the importance of considering the potential presentation of simultaneous etiologies in patients with multiple medical visits for unresolved febrile syndromes associated with risky exposure during agricultural activities.

Se presenta el caso de un hombre de 50 años de edad proveniente de la región de Urabá, Colombia, con una infección mixta por Rickettsia rickettsii y Leptospira interrogans serovar Copenhageni ST78, y pruebas negativas para malaria y dengue. El paciente presentó un síndrome febril que no mejoró con el tratamiento antibiótico sistémico y, finalmente, falleció en la unidad de cuidados intensivos. El diagnóstico post mortem se hizo mediante tipificación molecular de los dos agentes etiológicos. En la inspección del domicilio del paciente, se encontró un ejemplar de Rattus rattus infectado con L. interrogans del mismo serovar detectado en él. No se encontraron garrapatas en los animales domésticos que habitaban con el paciente. Se reporta una infección mixta con síntomas clínicos progresivos y fatales en un paciente con antecedentes laborales de riesgo en una zona endémica para enfermedades tropicales, lo que obliga a tener presente la posibilidad de infecciones simultáneas en personas procedentes de áreas endémicas que consulten reiteradamente por síndrome febril sin resolución y tengan riesgo laboral relacionado con actividades agrícolas.

Leptospirosis y rickettsiosis, reto diagnóstico para el síndrome febril en zonas endémicas / Leptospirosis and rickettsiosis, a diagnostic challenge for febrile syndrome in endemic areas

Resumen. Se presenta el caso de un hombre de 50 años de edad proveniente de la región de Urabá, Colombia, con una infección mixta por Rickettsia rickettsii y Leptospira interrogans serovar Copenhageni ST78, y pruebas negativas para malaria y dengue. El paciente presentó un síndrome febril que no mejoró con el tratamiento antibiótico sistémico y, finalmente, falleció en la unidad de cuidados intensivos. El diagnóstico post mortem se hizo mediante tipificación molecular de los dos agentes etiológicos. En la inspección del domicilio del paciente, se encontró un ejemplar de Rattus rattus infectado con L. interrogans del mismo serovar detectado en él. No se encontraron garrapatas en los animales domésticos que habitaban con el paciente. Se reporta una infección mixta con síntomas clínicos progresivos y fatales en un paciente con antecedentes laborales de riesgo en una zona endémica para enfermedades tropicales, lo que obliga a tener presente la posibilidad de infecciones simultáneas en personas procedentes de áreas endémicas que consulten reiteradamente por síndrome febril sin resolución y tengan riesgo laboral relacionado con actividades agrícolas.

Abstract. This is the case of a 50-year-old male from the region of Urabá, Colombia, with a mixed infection by Rickettsia rickettsii and Leptospira interrogans serovar Copenhageni ST78 and negative test for malaria and dengue fever. The patient presented with febrile syndrome and was unresponsive to systemic antibiotic treatment, who finally died in the intensive care unit. We established the postmortem diagnosis through molecular typification of the two etiological agents. In the inspection at the patient's home, we found a Rattus rattus specimen infected with L. interrogans of the same serovar found in him. We found no ticks parasitizing the domestic animals cohabitating with the patient. This case of a mixed infection with progressive and fatal symptoms in a patient with occupational risk in a tropical disease endemic zone highlights the importance of considering the potential presentation of simultaneous etiologies in patients with multiple medical visits for unresolved febrile syndromes associated with risky exposure during agricultural activities.

Human Rickettsiosis Caused by Rickettsia parkeri Strain Atlantic Rainforest, Urabá, Colombia.

We describe the clinical, serologic, and molecular findings of a new human rickettsiosis in Colombia. Antibodies against Rickettsia spp. were detected. PCR showed amplification of genes for R. parkeri strain Atlantic Rainforest. This new rickettsiosis of minor virulence could explain some of the undifferentiated acute febrile diseases in Colombia.

Importance of clinical and laboratory characteristics in the diagnosis of dengue and chikungunya co-infection: Probable case report / Importancia de las características clínicas y de laboratorio en el diagnóstico de las infecciones concomitantes por dengue y chikungunya: reporte de un caso probable.

We report the case of a 38-year-old woman who initially consulted for an undifferentiated fever. Although her clinical condition evolved with signs and symptoms compatible with dengue with alarm signs and that the anti-dengue IgM detection in a single sample indicated it was a probable case that could have happened during the previous three months, the patient kept consulting due to little improvement. On the tenth day after the onset of symptoms, she presented with painful polyarticular symmetric edema, as well as hyperpigmented lesions in the nasolabial fold. Chikungunya diagnosis was confirmed by the presence of IgM antibodies. In endemic countries for dengue and chikungunya, the possibility of co-infection exists, but it may go unnoticed. On the other hand, the co-infection may worsen the clinical course of these diseases. Therefore, physicians should evaluate the clinical and laboratory characteristics of both infections to be able to diagnose the coinfection for adequate management and to minimize complications.

Se presenta el caso de una mujer de 38 años que consultó inicialmente por fiebre indiferenciada. A pesar de que el cuadro clínico evolucionó con manifestaciones clínicas de dengue con signos de alarma y de que la detección de IgM antidengue en una sola muestra indicaba que se trataba de un caso probable que había podido ocurrir durante los tres meses anteriores, la paciente consultó de forma reiterada, pues no presentaba una mejoría significativa. En el décimo día del inicio de los síntomas, se observó edema simétrico en múltiples articulaciones acompañado de dolor, así como lesiones hiperpigmentadas en el surco nasogeniano. Se confirmó el diagnóstico de chikungunya por la presencia de anticuerpos IgM. Aunque puede pasar desapercibida, en los países endémicos para dengue y chikungunya existe la posibilidad de la infección concomitante, la cual puede agravar la evolución clínica de cada una de estas enfermedades. Por ello, es necesario que el médico considere las características clínicas y de laboratorio de ambas enfermedades para diagnosticar su presencia simultánea, garantizar un manejo adecuado y minimizar las complicaciones.

Malaria in Pregnancy in Endemic Regions of Colombia: High Frequency of Asymptomatic and Peri-Urban Infections in Pregnant Women with Malaria.

Background: Malaria in pregnancy (MiP) has been associated with adverse pregnancy outcomes. There is limited information on MiP in low transmission regions as Colombia. This study aimed to describe the epidemiology of MiP through active surveillance of infections by microscopy and polymerase chain reaction (PCR). Methods: A cross-sectional study was conducted between May 2016 and January 2017 in five municipalities (Apartadó, Turbo, El Bagre, Quibdó, and Tumaco) in Colombia. Pregnant women self-presenting at health centers for antenatal care visits, seeking medical care for suspected malaria, or delivery, were enrolled. Diagnosis of Plasmodium spp was made in peripheral and placental blood samples by microscopy and PCR. Results: A total of 787 pregnant women were enrolled; plasmodial infection was diagnosed by microscopy in 4.2% (95% CI 2.8-5.6; 33/787) or by nPCR in 5.3% (95% CI 3.8-6.9; 42/787) in peripheral blood. Most of the infections were caused by P. falciparum (78.5%), and 46% were afebrile (asymptomatic). Women in the first and second trimester of pregnancy were more likely to be infected (aOR = 3.06, 95%CI = 1.6 - 5.8). To live in the urban/peri-urban area (aOR = 3.04, 95%CI = 1.4 - 6.56), to have a history of malaria during last year (aOR = 5.45, 95%IC = 2.16 - 13.75), and the infrequent bed net usage (aOR = 2.8, 95%CI = 1.31 - 5.97) were associated with the infection. Pregnant infected women had a higher risk of anaemia (aOR = 2.18, 95%CI = 1.15 - 4.12) and fever (aOR = 14.2, 95%CI = 6.89 - 29.8). Conclusion: The screening for malaria during antenatal care in endemic areas of Colombia is highly recommended due to the potential adverse effects of Plasmodium spp. infection in pregnancy and as an important activity for the surveillance of asymptomatic infections in the control of malaria.

Importancia de las características clínicas y de laboratorio en el diagnóstico de las infecciones concomitantes por dengue y chikungunya: reporte de un caso probable / Importance of clinical and laboratory characteristics in the diagnosis of dengue and chikungunya co-infection: Probable case report

Se presenta el caso de una mujer de 38 años que consultó inicialmente por fiebre indiferenciada. A pesar de que el cuadro clínico evolucionó con manifestaciones clínicas de dengue con signos de alarma y de que la detección de IgM antidengue en una sola muestra indicaba que se trataba de un caso probable que había podido ocurrir durante los tres meses anteriores, la paciente consultó de forma reiterada, pues no presentaba una mejoría significativa. En el décimo día del inicio de los síntomas, se observó edema simétrico en múltiples articulaciones acompañado de dolor, así como lesiones hiperpigmentadas en el surco nasogeniano. Se confirmó el diagnóstico de chikungunya por la presencia de anticuerpos IgM. Aunque puede pasar desapercibida, en los países endémicos para dengue y chikungunya existe la posibilidad de la infección concomitante, la cual puede agravar la evolución clínica de cada una de estas enfermedades. Por ello, es necesario que el médico considere las características clínicas y de laboratorio de ambas enfermedades para diagnosticar su presencia simultánea, garantizar un manejo adecuado y minimizar las complicaciones.

We report the case of a 38-year-old woman who initially consulted for an undifferentiated fever. Although her clinical condition evolved with signs and symptoms compatible with dengue with alarm signs and that the anti-dengue IgM detection in a single sample indicated it was a probable case that could have happened during the previous three months, the patient kept consulting due to little improvement. On the tenth day after the onset of symptoms, she presented with painful polyarticular symmetric edema, as well as hyperpigmented lesions in the nasolabial fold. Chikungunya diagnosis was confirmed by the presence of IgM antibodies. In endemic countries for dengue and chikungunya, the possibility of co-infection exists, but it may go unnoticed. On the other hand, the co-infection may worsen the clinical course of these diseases. Therefore, physicians should evaluate the clinical and laboratory characteristics of both infections to be able to diagnose the coinfection for adequate management and to minimize complications.

Incidence and underreporting of leptospirosis comparing three diagnostic methods in the endemic region of Urabá, Colombia / Incidencia y subregistro de casos de leptospirosis diagnosticados con tres métodos diferentes en Urabá, Colombia

Introduction: Leptospirosis represents a public health problem and is a significant cause of morbidity and mortality in the region of Urabá. However, its notification reveals diagnostic limitations. Objective: To establish the incidence of leptospirosis in the municipalities of the so-called eje bananero in the Urabá region, to describe the magnitude of underreporting, and to propose guidelines for laboratory diagnosis by the public health network. Materials and methods: Two leptospirosis information sources were used: The national official surveillance system and a cross-sectional study of 479 acute-phase patients from April, 2010, to May, 2012. The diagnosis was made using three different tests: Indirect immunofluorescence, microagglutination test, and blood cultures. The exhaustiveness percentage of each information source was calculatedusing the capture and recapture test. Results: From the total number of cases, 58% (278/479) were positive for leptospirosis at least by a test and 10.43% (29/278) of cases were positive by all three methods. The inclusion of a native strain in the microagglutination test panel increased the percentage of positivity by 15%. The cumulative incidence rate was 66.5/100,000 inhabitants and the case fatality ratio was 2.15%. The underreporting rates of leptospirosis in the Urabá region were 27.8% in morbidity and 66.6% in mortality. Conclusion: Under-registration of leptospirosis in the region highlights the necessity to use more than one diagnostic test to identify Leptospira in patients from endemic areas. Underregistration could be a common situation throughout the country.

Introducción. La leptospirosis representa un problema de salud pública y es una causa importante de morbimortalidad en la región de Urabá, cuya notificación se ve afectada por las deficiencias en el diagnóstico. Objetivo. Establecer la incidencia de la leptospirosis en los municipios del llamado 'eje bananero' de la región de Urabá, documentar la magnitud del subregistro y proponer orientaciones para el diagnóstico por laboratorio por parte de la red de salud pública. Materiales y métodos. Se compararon dos fuentes de información sobre la leptospirosis: el sistema oficial nacional de vigilancia y un estudio transversal de 479 pacientes febriles, llevado a cabo entre abril de 2010 y mayo de 2012. El diagnóstico se hizo con base en tres pruebas: inmunofluorescencia indirecta, microaglutinación y hemocultivo. La exhaustividad de cada fuente de información se estimó mediante el método de captura y recaptura. Resultados. El 58 % (278/479) de los pacientes fueron positivos para leptospirosis, por lo menos, en una de las pruebas y, el 10,43 % (29/278), en las tres. La inclusión de una cepa nativa en el panel de la prueba de microaglutinación aumentó el porcentaje de positividad en 15 %. La tasa acumulada de incidencia fue de 66,5 por 100.000 habitantes y la proporción de letalidad fue de 2,15 %. El subregistro de la morbilidad por leptospirosis en la región de Urabá, fue de 27,8 % y, el de la mortalidad, de 66,6 %. Conclusión. El subregistro de leptospirosis en la región reitera la necesidad de usar más de una prueba diagnóstica para identificar Leptospira spp. en pacientes de zonas endémicas. Este subregistro podría ser una situación común en todo el país.

Successful treatment of cutaneous leishmaniasis with intralesional meglumine antimoniate: A case series.

Cutaneous leishmaniasis (CL) is a high-morbidity, vector-borne disease endemic to Colombia. Unlike conventional systemic antileishmanial therapy, intralesional meglumine antimoniate administration has fewer adverse effects and can be as effective and safe. We describe 12 patients treated with intralesional meglumine antimoniate: seven with primary and five with recurrent lesions. The majority (11/12) met all cure criteria after 1-7 sessions of meglumine antimoniate administration (1-5 mL). Adverse effects comprised mainly of local pain and edema. Intralesional meglumine antimoniate administration could be an excellent alternative treatment for uncomplicated CL; however, controlled clinical trials are needed to test the efficacy and safety thereof.

Incidencia y subregistro de casos de leptospirosis diagnosticados con tres métodos diferentes en Urabá, Colombia / Incidence and underreporting of leptospirosis comparing three diagnostic methods in the endemic region of Urabá, Colombia

Resumen Introducción. La leptospirosis representa un problema de salud pública y es una causa importante de morbimortalidad en la región de Urabá, cuya notificación se ve afectada por las deficiencias en el diagnóstico. Objetivo. Establecer la incidencia de la leptospirosis en los municipios del llamado 'eje bananero' de la región de Urabá, documentar la magnitud del subregistro y proponer orientaciones para el diagnóstico por laboratorio por parte de la red de salud pública. Materiales y métodos. Se compararon dos fuentes de información sobre la leptospirosis: el sistema oficial nacional de vigilancia y un estudio transversal de 479 pacientes febriles, llevado a cabo entre abril de 2010 y mayo de 2012. El diagnóstico se hizo con base en tres pruebas: inmunofluorescencia indirecta, microaglutinación y hemocultivo. La exhaustividad de cada fuente de información se estimó mediante el método de captura y recaptura. Resultados. El 58 % (278/479) de los pacientes fueron positivos para leptospirosis, por lo menos, en una de las pruebas y, el 10,43 % (29/278), en las tres. La inclusión de una cepa nativa en el panel de la prueba de microaglutinación aumentó el porcentaje de positividad en 15 %. La tasa acumulada de incidencia fue de 66,5 por 100.000 habitantes y la proporción de letalidad fue de 2,15 %. El subregistro de la morbilidad por leptospirosis en la región de Urabá, fue de 27,8 % y, el de la mortalidad, de 66,6 %. Conclusión. El subregistro de leptospirosis en la región reitera la necesidad de usar más de una prueba diagnóstica para identificar Leptospira spp. en pacientes de zonas endémicas. Este subregistro podría ser una situación común en todo el país.

Abstract Introduction: Leptospirosis represents a public health problem and is a significant cause of morbidity and mortality in the region of Urabá. However, its notification reveals diagnostic limitations. Objective: To establish the incidence of leptospirosis in the municipalities of the so-called eje bananero in the Urabá region, to describe the magnitude of underreporting, and to propose guidelines for laboratory diagnosis by the public health network. Materials and methods: Two leptospirosis information sources were used: The national official surveillance system and a cross-sectional study of 479 acute-phase patients from April, 2010, to May, 2012. The diagnosis was made using three different tests: Indirect immunofluorescence, microagglutination test, and blood cultures. The exhaustiveness percentage of each information source was calculatedusing thecapture and recapture test. Results: From the total number of cases, 58% (278/479) were positive for leptospirosis at least by a test and 10.43% (29/278) of cases were positive by all three methods. The inclusion of a native strain in the microagglutination test panel increased the percentage of positivity by 15%. The cumulative incidence rate was 66.5/100,000 inhabitants and the case fatality ratio was 2.15%. The underreporting rates of leptospirosis in the Urabá region were 27.8% in morbidity and 66.6% in mortality. Conclusion: Under-registration of leptospirosis in the region highlights the necessity to use more than one diagnostic test to identify Leptospira in patients from endemic areas. Under-registration could be a common situation throughout the country.

Successful treatment of cutaneous leishmaniasis with intralesional meglumine antimoniate: A case series

Abstract Cutaneous leishmaniasis (CL) is a high-morbidity, vector-borne disease endemic to Colombia. Unlike conventional systemic antileishmanial therapy, intralesional meglumine antimoniate administration has fewer adverse effects and can be as effective and safe. We describe 12 patients treated with intralesional meglumine antimoniate: seven with primary and five with recurrent lesions. The majority (11/12) met all cure criteria after 1-7 sessions of meglumine antimoniate administration (1-5 mL). Adverse effects comprised mainly of local pain and edema. Intralesional meglumine antimoniate administration could be an excellent alternative treatment for uncomplicated CL; however, controlled clinical trials are needed to test the efficacy and safety thereof.

Epidemiological characterization of incident cases of Rickettsia infection in rural areas of Urabá region, Colombia.

INTRODUCTION: Most of the studies related to rickettsial infection in Colombia are cross-sectional because of the challenge in conducting prospective studies on infectious disease that may have a difficult diagnosis. Although cross-sectional studies are essential to detect people exposed to rickettsiae, they are not suited to demonstrate the recent circulation of this pathogen in areas at risk of transmission. OBJECTIVE: To characterize the epidemiology of incident cases of Spotted fever group (SFG) rickettsial infection in humans and equines from rural areas of Urabá region in Colombia where outbreaks of rickettsiae previously occurred. MATERIALS AND METHODS: A prospective study was conducted in the Alto de Mulatos and Las Changas in the Urabá region. Serum samples and socio-ecological information were collected from 597 people enrolled in 2015, and a second sample was collected from 273 people a year later. Indirect immune-fluorescence assays for detection of IgG antibody against rickettsiae were done using slides with Rickettsia rickettsii antigens. A titer ≥128 was considered positive. Incident cases were defined as (i) serological conversion of IgG titers from seronegative to seropositive or (ii) at least a four-fold increase in IgG end point titers in the second sample. RESULTS: The cumulative incidence of rickettsial infection was 6.23% (95%CI 3.67-9.78) in humans and 32.31% (21/65) of incident cases in equines. Incident cases were mostly females (82.35%), the median age of cases was 41.02 years (IQR 18.62-54.1), and 29.41% reported tick bites during the study period. Results from multivariate analysis showed that removal of ticks after working outdoors is a protective factor for rickettsial infection (RR 0.26, 95%CI 0.08-0.84) and that a higher incidence of infection occurred in people who reported fever in the last year (RR 4.26, 95%CI 1.15-9.31). CONCLUSIONS: These results showed recent circulation of SFG rickettsiae in areas where previous lethal outbreaks have been reported, supporting the implementation of preventive measures to halt rickettsial transmission in the studied communities.

Wild and domestic animals likely involved in rickettsial endemic zones of Northwestern Colombia.

Between 2006 and 2008, three outbreaks of human rickettsiosis occurred in Northwestern Colombia (municipalities of Necoclí, Los Córdobas and Turbo), with case fatality rates between 27% and 54%. The aim of this study was to determine previous exposure of wild and domestic animals to spotted fever group (SFG) rickettsiae through serological tests, to detect rickettsial evidence in their ectoparasites, and to analyze their possible role in the epidemiology of rickettsial diseases in this zone of the country. A cross-sectional association study was performed from 2010 to 2011. Blood and ectoparasite samples were collected from domestic animals and small mammals. A statistically significant association (p<0.05) between seropositive animals and the study zones was observed. A total of 2937 ticks, 672 fleas and 74 lice were collected and tested in pools by PCR. The minimum infection rate (MIR) of the positive pools was 5% in ticks, 4% in fleas, and 0% in lice. Phylogenetic analyses showed circulation of three 4.Rickettsia species: R. felis in fleas, and R. bellii and Rickettsia sp. strain Atlantic rainforest, both in Amblyomma ovale ticks. In conclusion, this study demonstrated the occurrence of SFG rickettsiae in domestic, synanthropic and wild animals, and suggests the use of equines and canines as good sentinels of infection, in the study zone. We speculate that a transmission cycle exist involving rodents in the areas where these outbreaks have occurred. Tomes' spiny rats (Proechimys semispinosus) and common opossums (Didelphis marsupialis) could be good candidates as amplifier hosts for SFG rickettsiae in enzootic/endemic zones.

Human prevalence of the spotted fever group (SFG) rickettsiae in endemic zones of Northwestern Colombia.

In February 2006, an outbreak of human rickettsiosis occurred in the municipality of Necoclí Colombia, with 35% of lethality. This episode was, followed by two more, one in the municipality of Los Cordobas in 2007 with a 54% of lethality and the other one in the municipality of Turbo in 2008 with 27% of lethality. The aim of this study was to perform serological tests in healthy persons to determine the seroprevalence of antibodies against spotted fever group (SFG) rickettsiae and develop a survey to study some infection risk-related factors. A cross-sectional study was performed in 2011 and 2012. A blood sample and survey of associated factors was performed in healthy persons. A prevalence of 32%-41% was found in healthy people. From the multivariate analysis, we found that people living more than 16 years in these sites had a 79% higher risk of being seropositive and a 46% higher risk when they reported having birds in their houses if the variable of having a horse was included in the model. In conclusion, this study shows endemicity of at least one spotted fever group Rickettsia in the study zone.